Healthy Access Database
Tennessee Information Directory
Employer-Based Health Insurance Coverage
Small Employer Groups
Definition
2-50 employees.
Guarantee Issue Requirements
As per the federal Health Insurance Portability and Accountability Act of 1996, all health insurance contracts for employer-groups of 2-50 employees must be issued on a guarantee-issue basis. All group insurance contracts must also be guarantee-renewable, unless there is non-payment of premium, the employer has committed fraud or intentional misrepresentation or the employer has not complied with the terms of the health insurance contract.
Preexisting Condition Requirements
As per the federal Health Insurance Portability and Accountability Act of 1996, all group health insurance carriers can impose a 6-month look-back/12-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage.
Underwriting Requirements
In the small group market in Tennessee, private health insurance carriers can medically underwrite rates. Rates may vary by plus or minus 35 percent of the indexed rate based on the health status of the group.
Creditable Coverage Requirements
As per the federal Health Insurance Portability and Accountability Act of 1996, credit for prior coverage isrequired as long as there is no more than a 63-day break in coverage.
Large Employer Groups
Definition
51 or more employees.
Issuance of Coverage
Large group health insurance contracts, unlike small group health insurance contracts, do not have to be offered on a guarantee-issue basis. Large group health insurance is medically underwritten at the time of purchase, with rates based on employee participation and prior claims experience. However, as per the federal Health Insurance Portability and Accountability Act of 1996, all group insurance contracts, including large group contracts, must be guarantee-renewable, unless there is non-payment of premium, the employer has committed fraud or intentional misrepresentation or the employer has not complied with the terms of the health insurance contract.
Creditable Coverage Requirements
As per the federal Health Insurance Portability and Accountability Act of 1996, credit for prior coverage is required as long as there is no more than a 63-day break in coverage.
Continuation of Coverage Options
COBRA
Many organizations that employ more than 20 people and offer health benefits are required to allow employees and their dependents to temporarily continue their health insurance coverage for specified time periods and under specified conditions even after they would no longer be traditionally eligible for that coverage. The federal legislation that requires this is known as the Consolidate Omnibus Budget Reconciliation Act of 1985 (COBRA). This section explains people's rights under COBRA, which do not vary by state.
Qualifying Events
State Continuation and/or Individual Conversion Plans
Overview of State Continuation/Mini-COBRA Requirements
Individuals and their dependents in an employer group of 2-19 employees who are terminated from health insurance coverage can obtain up to 3 months of continuation coverage under the group plan. Individuals must have at least 3 months of prior coverage under the group plans and must elect the continuation option within 30 days. Individuals must pay 100% of their group premium to participate.
Conversion Plan Requirements
Individuals who are transferring out of a group plan have the option of selecting an individual conversion product, exhausting COBRA or continuation coverage.
HIPAA Group-to Individual Portability Coverage
Explanation
Individuals who have been in enrolled in a group health plan and decide to leave that group health plan and purchase individual market coverage have certain rights under the federal Health Insurance Portability and Accountability Act of 1996. States must provide at least one guarantee-issue option for those individuals to purchase individual market insurance, as long as that coverage is purchased within 63 days of disenrollment from the group plan. Individuals who have access to COBRA must first exhaust COBRA coverage before exercising their HIPAA rights, unless specified by the state. Individuals with less than 12 months of creditable coverage may be eligible for partial credit, based on the length of creditable coverage they do have available.
Tennessee has elected the federal fallback option for portability under HIPAA Individual market health insurance carriers must: 1) offer all of their products; 2) offer its two most popular plans; or 3) offer two representative plans with higher and lower levels of coverage, on a guarantee-issue basis to HIPAA-eligible individuals.
Exhaustion of Other Coverage Requirements
Individuals must exhaust their COBRA benefits or similar state program benefits if available to them before exercising their HIPAA rights. Individuals also cannot currently be eligible for Medicare or Medicaid or covered under any other health insurance.
Creditable Coverage Requirements
Individuals must have at least 18 months of prior creditable coverage. The most recent prior coverage must have been group health insurance coverage offered by a health insurance issuer, group health plan, government plan or church plan. Individuals may not have had a prior coverage break of more than 63 days.
Other Requirements
Individuals must be Tennessee residents.
Individual Health Insurance Coverage
Traditional Private Individual Health Insurance
Underwriting Requirements
Medical underwriting is allowed without restriction.
Rating Restrictions
There are no caps on individual health insurance rates in Tennessee.
Issuance of Coverage
The individual market serves as the guarantee issue option for individuals exercising their HIPAA group-to-individual portability rights in Tennessee. The use of elimination riders is allowed, except for HIPAA-eligible individuals.
Preexisting Condition Requirements
Pre-existing conditions may not be considered for HIPAA-eligibles in the Tennessee individual health insurance market. However, there is no look-back or exclusionary period limit for pre-existing conditions for other individual policies.
Creditable Coverage Requirements
Credit for prior coverage is not required, except for HIPAA-eligibles.
Coverage for Medically Uninsurable Individuals
Guarantee Issue Requirements
General
In Tennessee, traditional individual market health insurance coverage is not sold on a guarantee issue basis.
HIPAA Group-to Individual Portability Coverage
In Tennessee, individuals exercising their federal group-to-individual health insurance rights provided by the Health Insurance Portability and Accountability Act of 1996 can obtain guarantee-issue private individual health insurance coverage through any individual market health insurance carrier.
High-Risk Health Insurance Pools
Eligibility Criteria
No income or asset restrictions exist for AccessTN.
Must be a U.S. citizen or qualified legal alien and a Tennessee resident for at least 6 months; age 19 or over; uninsurable by medical or insurance determination as demonstrated by one of the following:
a. A doctor's statement that applicant has one of 55 medical conditions pre-approved for presumptive eligibility
b. Denial by two unaffiliated insurance carriers for individual coverage due to a health-related condition
c. Qualification through an AccessTN contracted underwriting process
No access to insurance at time of application; or exhausted continuation of coverage (including COBRA)
A special temporary waiver is available for TennCare disenrollees who have secured HIPAA coverage
Overview of Benefits
Comprehensive coverage is available and covers inpatient and outpatient care, prescription drugs, doctor visits, mental health parity, chemical dependency, home health visits, preventive care and maternity among other benefits.
Overview of Coverage Options
A PPO plan is offered with deductibles of $1000 $2500, and $5000.
Preexisting Condition Requirements
A three-month pre-existing condition exclusion. Outpatient pharmacy and chemotherapy/radiation performed in an outpatient setting are not subject to the exclusion.
Rate Restrictions
Pool premiums are capped at 200 percent of the base individual market rate.
Other State Options
Overview of State Alternative
Assistance for Obtaining Health Coverage
Medicaid
Income Requirements
Children
Children (ages 1-5)-133% of the Federal Poverty Level for children who meet a medical eligibility test. Other children with family incomes of 100% of the Federal Poverty Level are eligible.
Children (Ages 6-19)-100% of the Federal Poverty Level for children who meet a medical eligibility test. Other children with family incomes of 100% of the Federal Poverty Level are eligible.
Pregnant Women and Infants
Pregnant Women-185% of the Federal Poverty Level
Infants (ages 0-1)-185% of the Federal Poverty Level for children who meet a medical eligibility test. Other infants with family incomes of 100% of the Federal Poverty Level are eligible.
Parents
Non-Working Parents-100% of the Federal Poverty Level
Working Parents-100% of the Federal Poverty Level
(Parents must meet a medical eligibility test in order to qualify.)
Other Populations
Medically Needy Individual-34% of the Federal Poverty Level
Medically Needy Couple-27% of the Federal Poverty Level
Supplemental Security Income Recipients-74% of the Federal Poverty Level
Asset Requirements
Asset and resource requirements vary based on the Medicaid program for which an individual is applying. Limits range from $2000-6000. There are no asset or resource requirements for children or pregnant mothers.
Other Enrollment Requirements
All Medicaid/TennCare applicants are required to meet citizenship requirements, provide a social security card or apply for one, be a resident of Tennessee, assign third party benefits and be willing to apply for other benefits.
Overview of Benefits and Covered Services
Tennessee Medicaid coverage must provide:
Inpatient hospital services.
Outpatient hospital services.
Prenatal care.
Vaccines for children.
Physician services.
Nursing facility services for persons aged 21 or older.
Family planning services and supplies.
Rural health clinic services.
Home health care for persons eligible for skilled-nursing services.
Laboratory and x-ray services.
Pediatric and family nurse practitioner services.
Nurse-midwife services.
Federally qualified health-center (FQHC) services, and ambulatory services of an FQHC that would be available in other settings.
Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21.
Cost Information
Some Tennessee Medicaid recipients are required to pay co-payments for prescription drugs. Pregnant women, children, and hospital or nursing home patients who are expected to contribute most of their income to institutional care are exempt from cost-sharing requirements. In addition, all Medicaid beneficiaries are exempt from co-payments for emergency services and family planning services.
State Children's Health Insurance Program
Eligibility Requirements
Income Requirements
The TennCare CHIP program provides coverage to uninsured children under age 19 with family income at or below 100 percent of the Federal Poverty Level (FPL).
Other Eligibility Requirements
Individuals must be under age 19, Tennessee residents and U.S. citizens or qualified residents.
Crowd-Out Requirements
None.
Overview of Benefits and Covered Services
TennCare benefits include:
Inpatient Hospital Services
Outpatient Hospital Services
Physician Inpatient Services
Physician Outpatient Services
Physical Exams and Check-ups
Lab and X-ray Services
Hospice Care
Home Health Services
Dental Services
Vision Services
Pharmacy Services
Durable Medical Equipment
Emergency Air and Ground Ambulance
Non-Emergency Transportation
Renal Dialysis Services
EPSDT Services
Chiropractic Services
Private Duty Nursing
Reconstructive Breast Surgery
Speech Therapy
Occupational Therapy
Physical Therapy
Organ Transplant and Donor Organ Procurement
Convalescent Care
Psychiatric Inpatient Facility Services
Physician Psychiatric Inpatient Services
Outpatient Mental Health Services
Mental Health Crisis Services
Inpatient and Outpatient Substance Abuse Treatment Services
Mental Health Case Management
Integration with Employer-Based Coverage
There is no integration with a parent's potential employer based coverage at this time.
Parental Benefits
The CHIP portion of TennCare only covers children under age 19. Parents may be eligible under other portions of the TennCare program.
Cost Information
There are no cost-sharing requirements.
Federal Health Care Tax Credit Program
Eligibility Requirements and Rights
This section provides detailed information about eligibility for the HCTC Program.
Purchasing Options
COBRA
Individuals can use federal Health Care Tax Credit funds to pay for COBRA continuation coverage, as long as the employer or former employer contributes less than 50% of the total health plan premium.
The COBRA Provisions only apply to federally mandated COBRA continuation coverage, which applies to employer-groups who employed 20 or employees in the prior year, and requires them to provide the option of temporarily continuing group coverage to individuals when their group health coverage is lost due to certain specific events. State continuation coverage mandates, which may apply to smaller group health plans may not necessarily be an approved mechanism to spend federal Health Care Tax Credit funds. Individuals also may not use Health Care Tax Credit funds to pay for employer-sponsored premiums if the employer is voluntarily providing some type of continuation benefit that is not the same as federally mandated COBRA.
Qualified Spouse's Plan
Individuals can use federal Health Care Tax Credit funds to pay for employer-sponsored health insurance they receive through their spouse's employer, provided that the employer pays no more than 50% of the total family premium (which includes any amount that the employer pays for the spouse's coverage).
Qualified Individual Health Insurance Coverage
Individuals can use federal Health Care Tax Credit funds to pay for private individual heath insurance coverage, provided that they were enrolled in such coverage for at least the last 30 days before they were separated from the job that makes them eligible for TAA benefits or for payments from the Pension Benefit Guarantee Corporation.
State-Elected Option(s)
In Tennessee, individuals who are eligible for the federal Health Care Tax Credit can use their credit funds to purchase specified private coverage through Blue Cross Blue Shield of Tennessee.